EBV treatment in hyperinflated patients with heterogeneous emphysema without collateral ventilation resulted in clinically meaningful benefits in lung function, dyspnea, exercise tolerance, and quality of life, with an acceptable safety profile. Clinical trial registered with www.clinicaltrials.gov (NCT02022683).

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause severe pneumonia requiring invasive mechanical ventilation [1], in the context of atypical acute respiratory distress syndrome (ARDS) [2]. The magnitude of the epidemic places an unprecedented pressure on intensive care units (ICUs), making avoidance of intubation a critical issue. Supplemental oxygen is the first-line treatment of ARDS. When escalation is needed, pre-intubation approaches carry the risk of delaying intubation and increasing mortality [3]. Noninvasive ventilation (NIV) is not recommended [4] but high-flow nasal oxygen (HFNO) may decrease the need for intubation without impacting mortality [4, 5]. Mostly because of an early negative report [6], continuous positive airway pressure (CPAP) remains largely undocumented in ARDS. In SARS-CoV-2 pneumonia, evidence-based guidelines are lacking [7] but CPAP could prove useful [8]. In this context, on 20 March, 2020, the French learned society for respiratory medicine circulated a clinical management algorithm derived from the Italian experience and suggesting the use of CPAP in SARS-CoV-2 patients requiring oxygen escalation [8]. This algorithm was implemented in our department on 24 March, 2020, in a context of limited HFNO availability and environmental contamination concerns. We designed this retrospective study to evaluate the impact of the CPAP strategy on intubation rate. We compared the period immediately before the algorithm implementation (11-23 March, 2020) with the period immediately after (24 March to 8 April), testing the hypothesis that CPAP can avoid intubation in patients with severe forms of SARS-CoV-2 pneumonia over the first week of their management. This observational study with short-term historical controls was conducted in the 25-bed pulmonology unit of a 1600-bed university hospital (Pitié-Salpêtrière, Paris, France). It was approved by the institutional review board of the French learned society for respiratory medicine (CEPRO2020-024). Patients were informed of the use of their anonymised data and given the opportunity to refuse it.

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